If you’re a person with chronic pain, ask yourself how often you experience the following sort of thoughts: “I feel like I can’t stand it anymore,” “I want this pain to go away so badly,” “I can barely think of anything else and it overwhelms me,” “I’m afraid this pain will only get worse?”
If these thoughts are familiar to you, you may be suffering from what psychologists call pain catastrophizing. Pain catastrophizing is one of the strongest predictors of suffering in chronic pain patients. The good news is, catastrophization is highly treatable with the use of empirically-supported therapy techniques intended to bring awareness to and restructure harmful thoughts.
Beth Darnall, Ph.D. is a clinical psychologist specializing in pain, and is an associate professor in the Division of Pain Management at Stanford University. She’s been working with people who suffer from chronic pain for over 15 years, and more recently specializing in patients about to undergo surgery in order to ready them for their procedures. Karuna Labs recently caught up with Dr. Darnall, and asked her about her insights into the psychology of pain.
Karuna: What do you most want people to understand about your work?
Dr. Beth Darnall: Most people have misinformation about role of psychology in the treatment of pain. Historically, the focus of pain treatment was medication, procedures, and surgeries. It was only when medical treatments were ineffective that anyone raised the question of behavioral interventions or pain psychology, which led to the perception that pain psychology is a palliative option, or the option of last resort when nothing else works. But it turns out that this is simply not the case.
My work focuses on changing a cultural mindset about the role of psychology in the experience and treatment of pain, such that we elevate psychology to the status of primary treatment. Collectively, research findings tell us that pain psychology deserves top billing.
Karuna: Why do you believe that pain psychology should be the primary treatment for chronic pain?
Dr. Beth Darnall: Psychology is built into the definition of pain. Pain is not just noxious sensory experience, but an emotional experience too. The fact that we don’t integrate it equally into our treatment is the main reason that people have suboptimal results. Often, cognitive and emotional, behaviors that maintain or even amplify pain are ignored. At this point, we have a lot of rich data that demonstrates that if psychological factors aren’t addressed on at the front end, they will serve to undermine patients’ response to the interventions we try. If we integrate pain psychology early and equip patients with the skills they need to self-regulate, it optimizes their response to surgeries, medications, or whatever procedures may also be used to treat their pain.
It’s not either medicine or psychology – people need both.
Karuna: What is your approach to pain psychology?
Dr. Beth Darnall: The psychological piece needs to be addressed first in order to optimize patients’ response to everything else. In order to ready people as quickly as possible, I have developed a brief treatment to address pain related distress, common factor, and pain catastrophizing. I have developed a single session treatment – a 2 hour class – to do so. Usually, pain cognitive behavioral therapy (CBT) lasts 8 session, so this is much more efficient and inexpensive for patients.
Karuna: What would a patient learn in the 2 hour class?
Dr. Beth Darnall: Pain education and skills. People have their own experience of pain, so we all think we know what that is, but the class actually unpacks why psychology is integral when it comes to chronic pain. The class includes pain science and basic CBT skills. We distill 8 CBT sessions into one focal compressed module. We also know that when CBT is effective, it’s often because catastrophizing has been reduced, which may mean catastrophizing is the most effective therapeutic target.
Karuna: What can you tell us about pain catastrophizing?
Dr. Beth Darnall: The research shows that pain catatrophizing is a specific psychological experience that is highly predictive of treatment outcome. It often comes with rumination, magnification, and feelings of helplessness. Rumination has the most predictive value. When our minds are connected to pain so strongly, it makes it hard to reduce pain because it’s so front and center. This is confusing to people with chronic pain; they’ll say, “of course I’m focused on my pain, it’s severe and I can’t focus on anything else.” My approach is similar to the broader field of cognitive behavioral therapy: it requires unpacking how a person’s attention relates to their pain and what they can do to use specific skills to disengage that focus. Any skills one can use to disengage negative focus from the pain tend to engender a sense of how a person can help themselves. By learning ways to stop ruminating, we reduce feelings of helplessness.
Karuna: What about mindfulness?
Dr. Beth Darnall: There is a therapy approach called Acceptance and Commitment Therapy (ACT) that combines CBT with mindfulness. I don’t have formal training as an ACT therapist but I use some of the techniques. ACT has many of the same components of CBT but also focally integrates mindfulness with more emphasis on setting active goals. ACT uses different types of cognitive strategies; in CBT often the emphasis is on restructuring and reframing, whereas ACT uses techniques meant to generate more cognitive flexibility. The idea is that much of our thinking is rooted in absolutes, or binary thinking. In the end, there are more than 100 types of technique someone could diffuse a persistent thought that’s essentially unhelpful. One could be repeating a thought again and again until it loses its value, which allows the patient to begin witnessing those thoughts without reaction or emotional attachment to them. There are many useful ways to approach your pain more adaptively.
Karuna: Thank you, Dr. Darnall, for your insights!